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Full text of "United States Navy Medical News Letter Vol. 33 No. 7, 3 April 1959"

Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Leslie B. Marshall MC USN (RET) - Editor 



Vol. 33 



Friday, 3 April 1959 



No. 7 



TABLE OF CONTENTS 



Historical Fund of the Navy Medical Department 2 

Medical Problems of Modern Warfare and Civil Disaster 3 

Ectopic Pregnancy 9 

Acute Granulocytic Leukemia in Pregnancy 12 

Periureteric Fibrosis 14 

Treatment of Scleroderma 16 

Rehabilitation 18 

Air Pollution - A Menace to Public Health 21 

IN MEMORIAM 23 

From the Note Book 24 

Medical Intelligence Reports (Med-3820-l) 25 

Additional Personnel Assignments 26 

American Board Examinations in Obstetrics ajid Gynecology 26 

Forty-Fourth Session of Trudeau School of Tuberculosis 27 

Procurement of Deratting Certificate (BiiMed Inst. 6250.7) 27 

DENTAL SECTION 

Silver Amalgam 28 

Articles by Dental Officers in ADA Journal 29 

Dental Interns for Fiscal Year I960 30 

RESERVE SECTION 

Meeting of the American Medical Association 31 

Meeting of American Optometric Association 32 

Notice to Commandant of Change of Mailing Address 32 

PREVENTIVE MEDICINE SECTION 

Mosquito -Borne Encephalitis ... 33 Schistosomiasis Mansoxd 35 

Snakes and Encephalomyelitis ... 34 Artificial Respiration 37 

Navy's Motor Vehicle Traffic Safety Course 40 



Medical News Lietter, Vol, 33, No. 7 



HISTORICAL FUND 
of the 
NAVY MEDICAL DEPARTMENT 



A committee has been formed with representation from the Medical 
Corps, Dental Corps, Medical Service Corps, Nurse Corps, and 
Hospital Corps for the purpose of creating a fund to be used for the 
collection and maintenance of items of historical interest to the Medical 
Department. Such items will include, but will not be limited to, por- 
traits, memorials, etc., designed to perpetuate the memory of dis- 
tinguished members of the Navy Medical Department. These memorials 
will be displayed in the Bureau of Medicine and Surgery and at the 
National Naval Medical Center. Medical Department officers, active 
eind inactive, are invited to make small contributions to the fund. It is 
emphasized that all donations must be on a strictly voluntary basis. 
Funds received will be deposited in a Washington, D. C. bank to the 
credit of the Navy Medical Department Historical Fvind, and will be 
expended only as approved by the Committee or its successor and for 
the objectives stated. 

It is anticipated that an historical committee will be organized at each 
of our medical activities. If you desire to contribute, please do so 
through your local historical committee or send your check direct, 
payable to Navy Medical Department Historical Fund, and mail to: 

Treasurer, N. M. D. Historical Fund 
Bureau of Medicine and Surgery (Code 14) 
Department of the Navy 
Washington 25, D. C. 



Committee 

F. P. Gilmore, Rear Admiral (MC) USN, Chairman 
C. W. SCHANTZ, Rear Admiral (DC) USN 
L. J. ELSASSER, Captain (MSC) USN 
R. A. HOUGHTON, Captain (NC) USN 
T. J. HICKEY, Secretary-Treasurer 



Medical News Lretter, Vol, 33, No. 7 



Me dical Problem s of Modern Warfare 
and Civil Disaster 

For many generations, th.e medical profession and the allied medical 
sciences have been involved in the seemingly endless task of dealing with 
man's adaptation to the environment in %which he lives. In the past, the 
environment has consisted in the main of natural forces, such as climate, 
food, water, shelter, protective clothing, reproduction of the species, 
and a liberal admixture of worship and fear. Now, with the advent of indus- 
trialization of so many parts of the world, new forces in the production of 
traumatic injury to man, including the onslaughts of biological effects, 
have been encoxintered. Radiation energy, a force having phenonnenal bio- 
logical and physiological implications, was destined to have a profound 
effect, not only on the lives of men, but on all mankind and his environment 
as well. 

On December 2, 1942, Fermi and co-workers produced the first self- 
sustained nuclear chain reaction by employing a highly fissionable material. 
Just a few years later, this nuclear reactor becanne a weapon of war and 
the terrific energies produced were added to man's environment. With the 
manufacture of this weapon in sufficient quantities to produce a devastating 
effect in man's environment, the medical profession and allied science 
specialists of the world were charged with the responsibilities of developing 
accurate knowledge of the biological and kinetic effects of this energy, and 
of assisting in plans, logistics, and training programs for the care of stag- 
gering numbers of human casualties which could be expected in the event of 
atomic or thermonuclear attack. 

Not only was the military interested in this colossal problem and chal- 
lenge, but the term, "civil defense, •' became a byword as non-combatants 
were no longer immune to the devastating effects of these nuclear weapons. 

The collective efforts of highly qualified and carefully selected scien- 
tists in the field of nuclear research have been channeled through top level 
committees of the nation for evaluation and coordination of the total efforts. 
Some are: (1) The Division of Biology and Medicine of the United States 
Atomic Energy Comnriission, (2) The Committee on Genetic and Somatic 
Effects of the National Academy of Sciences of the National Research Council, 
and (3) the National Committee on Radiation Protection centered at the 
National Bureau of Standards, Washington, D. C. 

Recent developments in ABC or thermonuclear, biological, and chem- 
ical warfare, the use of nuclear power, and radioactive isotopes have accen- 
tuated the problems in medical defense and radiation protection and, in 
certain instances, have created new ones. The Special Weapons Defense 
Division of the Bureau of Medicine and Surgery of the Navy Department 
has the responsibility for recommending policy and for furnishing guidance 
concerning these problems to the Surgeon General and, thus, to the Medical 
Department at large. 



Medical News Letter, Vol. 33, Na. 7 



One of the most difficult aspects of planning for ABC warfare medical 
defense and radiation protection is a delineation of responsibilities of the 
Medical Department. This, of necessity, requires a thorough knowledge 
of the medical aspects of the problems in relation to the over -all problems. 

The areas of responsibility of the Bureau of Medicine and Surgery as 
outlined in OpNav Instruction 2440. 3 are to: 

1. Develop procedures and develop, procure, and distribute eqiiip- 
ment and materials for the treatment of mass casualties resulting from 
atomic, biological, and chemical warfare attacks. 

2. Advise agencies responsible for the provision of protection, decon- 
tamination, and detection devices as to medical aspects involved in their 
operation or development. 

3. Develop techniques and develop, procure, and distribute devices 
for the rapid identification of biological warfare agents. 

4. Investigate and develop nneans of increasing the resistance of 
individxials to the effects of atomic, biological, and chemical warfare 
agents. 

5. Establish tolerance and regulations for radiation and provide infor- 
mation on physiological effects of exceeding such tolerances by varying 
amoxints. 

6. Train medical and paramedical personnel as required; develop 
adequate atoniic, biological, and chemical warfare defense concepts and 
realistic techniques. 

7. Indoctrinate all hands in the elements of "buddy aid, " self aid, 
and first aid. 

The United States Navy Passive Defense Manual outlines defense plan- 
ning responsibilities, organization, general concepts of passive defense 
operations, relation to civil defense, the niake-up and f\inction of standard 
passive defense teams and a compilation of laws, executive orders, and 
regulations pertaining to domestic emergencies, passive defense, civil 
defense, and related problems. 

The instructions indicate the areas of management, technical, and 
operational responsibilities which must be considered in the preparation 
and implementation of local passive defense bills. To assist in preparation 
and interpretation of the instructions by the Special Weapons Defense Division 
of the Bureau of Medicine and Surgery, progress has been made with regard 
to a delineation of the Medical Department's technical and operational 
responsibilities within the over-all passive defense organization. The 
prinnary responsibilities of the Medical Department which are involved 
in this delineation are; 

1. Advisory. 

2. Prophylaxis and therapy (prophylaxis mainly applicable to bio- 
logical warfare defense.) 



Medical News Letter, Vol. 33, No. 7 



3. laatrnction in self aid and first aid which has hees. standardized 
on a Navy -wide basis (mainly applicable to atomic warfare and chem- 
ical warfare). 

4. Mass casualty handling and evacuation. 

5. Epidemiological cotintermeasures in biological warfare including 
epidemic intelligence in recognition of a biological warfare attack. 

6. Training of medical and paramedical personnel. 

7. Indoctrination of all personnel in the medical aspects of ABG 
warfare. 

8. Decontamination of actual casualties {not of other personnel). 

9. Detection of ABC contamination in certification of food and water 
for consumption, (not in the general environment). 

10. Identification of biological warfare agents. 

11. Recording and accountability for personnel exposed to ionising 
radiation. 

The responsibilities of the Medical Department in various situations 
are considered; first, the duties of the Medical Department in a nonmedical 
command, such as ship or station. The pre>attack duties logically come 
£Lrst and among these, in addition to advisory fiinctions, are planning, indoc- 
trination of all hands in the medical aspects of atomic, biological, and chem- 
ical warfare defense, prophylactic procedures in prevention of biological 
warfare casualties, and thorough teaching of first aid, self aid, and "buddy 
aid" to all personnel. These pre-attack duties are closely tied together. 
Planning means, in part, preparing a medical annex to the passive defense 
bill of the ship or station. The Medical officer needs adequate training if he 
is to fulfill his duties in ABC warfare defense. The courses now given in 
this subject at the Naval Schools Command, Treasure Island, Calif. , and 
other Naval and Army facilities are stressing planning concepts that will be 
helpful at all operational levels. 

Among the clearly delineated post-attack duties of the Medical Depart- 
ment are: triage (sorting of casualties); treatment of casualties including 
post-exposure prophylactic procedures; decontamination of casualties (but 
not decontamination of non-casualties); advisory capacity function concerning 
decontamination of non-casualties and water and food supply control; eval- 
uation of potential casualties, such as asymptomatic radiation exposures, 
biological warfare exposures, if known, and personnel exposed to war gases 
having a latent period. 

Post-attack duties include several functions which need clarification. 
The decontamination of personnel (with the exception of actual casvialties) 
is not the responsibility of the Medical Department. Actually, the only 
decontamination that is the responsibility of the Medical Department is the 
decontamination of casualties, and this for the obvious reason that a severely 
wounded man must come to the Medical Department for treatment as soon as 
possible. Decontamination, in general, of personnel as well as of material. 



Medical News Letter, Vol. 33, No. 7 



is the responsibility of the damage control department on shipboard and 
the responsibility of sinnilar nonmedical personnel ashore. The rationale 
for not assigning this responsibility to the Medical Department is that thd 
Medical Department, at the time of enemy attack, will be overloaded with 
purely medical duties and must not be saddled with additional responsibil- 
ities. 

Another duty about which confusion appears to exist in regard to res- 
ponsibility is in the detection and identification of biological warfare agents. 
Consistent with their responsibilities, the development of physical devices 
for rapid detection of biological warfare agents is the responsibility of the 
Bureau of Ships afloat, and the Bureau of Yards and Docks ashore. These 
devices are intended to reveal the presence of viable, airborne, pathogenic 
agents, and their use is regarded as a warning procedure. Their continued 
developnnent and operation will be the responsibility of nonmedical personnel 
as are other types of warning devices. Biological methods of detection and 
identification shall be accomiplished by nonmedical personnel. 

Since the strictly biological identification procedures are a clear-cut 
responsibility of Medical Department personnel, the operation of sanapling 
devices, both present and future, should be at least under the advisory 
supervision, but not necessarily the control, of the Medical Department. 

Detection of ABC contamination of food and water and identification 
of the BW and CW agents therein are Medical Department responsibilities 
in which sampling may of necessity have to be done by nonmedical person- 
nel Tinder general medical supervision because of the press of other duties. 
Identification of the BW agents, because of the techniques involved, can 
only be done by medical personnel and the final certification of the safety 
of the food and water can only be made by the Medical Department. Treat- 
ment of water and food to naake them safe for consumption is not a Medical 
Department responsibility, but close collaboration with medical personnel 
will be necessary in order to obtain Medical Department certification. 

The advent of the atomic and thermonuclear -type weapons has nec- 
cessitated many changes in the concept of modern warfare. If the Medical 
Departinent is to assume its traditional role in the next conflict, it must 
prepare now to render service in the face of weapons of far greater des- 
tructive power than was exhibited by the bombs which fell on Hiroshima 
and Nagasaki. Very little imagination is needed to transpose such a scene 
to any United States military or naval base. 

The attack will not come on a predetermined D-day — rather, it will 
be at the enemy's convenience. There will be no time to mobilize or for- 
mulate plans during the initial attack and, since the targets of these weapons 
are expected to sustain large numbers of casualties, the role of the Medical 
Department will be more important than ever. Germany's experience during 
World War 11 emphasized the fact that medical services must play a primary 
role in the initial phase of any recovery plan, for morale purposes if for no oth**- 
reason. 



Medical News Letter, Vol. 33, No. 7 



Recognizing the importance of ABC defense training programs, the 
Bureau of Medicine and Surgery, in 1948, directed the Naval Medical School 
of the National Naval Medical Center, Bethesda, Md. , to prepare a five- 
day course in the medical aspects of special weapons. This course was 
enthusiastically received and has been repeated from one to four times each 
year. In 1953, the course was extended to two weeks. The present course 
is an intensive review of the medical problems associated with nuclear, 
biological, and chemical warfare; it includes an introduction to nuclear 
physics, weapons systems, the problems of space medicine, the manage- 
ment of mass casualties, civil defense, and military stress patterns. The 
March 1958 presentation reemphasizes the employment and capabilities of 
strictly conventional weapons. 

For several years. Medical officers have participated in the Line 
Atomic, Biological, and Chemical Defense Course. In Janiiary 1958, a four 
weeks' course in ABC warfare defense was organized for Medical officers 
and will be given twice each year. Special weapons orientation courses are 
also available at various activities. 

In the Center for biological warfare training, MedicaJ. Department 
officers are assigned to the research program. In chemical warfare training 
programs. Medical Service Corps officers are on the teaching staffs. The 
Bureau of Medicine and Surgery has regularly filled the available billets 
in the one week courses in the Management of Mass Casualties. 

Atomic propulsion has created a priority requirement for nuclear 
trained submarine Medical officers. These officers receive basic submarine 
medical training over a period of six months. They are then ordered to a 
submarine squadron for six months' operational experience; next, they are 
assigned for an academic year of training in radiobioloby leading to a 
Master of Science degree. Subsequently, each officer is ordered to a reac- 
tor site for engineering indoctrination for periods varying from three months 
to one year. These officers are then ordered to their respective nuclear 
powered submarines prior to the installation of the reactor core. 

In September 1958, the Naval Medical School initiated a course for 
Nurse Corps officers in clinical isotope techniques with emphasis on the 
nursing care of patients under study with isotopes and the management of 
nuclear casualties. It is the intention of the Bureau to train a sufficient 
number of Nurse Corps officers to permit assignment of one gradxiate to 
each of the larger naval hospitals. 

Correspondence courses prepared and administered by the Naval 
Medical School are available to regular and reserve officers of the three 
services. Courses in atomic medicine and the treatment of chemical war- 
fare casualties are extremely popular. New courses in radioisotope tech- 
niques ... in atomic, biological, and chemical defense . . . and the 
management of mass casualties have been prepared. 

For the training of medical support personnel, the Naval Medical School 
publishes a variety of manuals designed as laboratory and field guides. Within 



Medical News Letter, Vol. 33, No. 7 



the p^st two years, tliree new manuals have been prepared and four have 
been completely revised. A new x-ray meuoual la in press and a new radioi- 
active isotope therapy technicians' manual has been completed. It is the 
policy of the Naval Medical School to make these manuals available without 
cost to the military services, the public health service, civilian physiciai&s, 
medical students, and technicians. 

In December 1957, the Secretary of the Navy directed that the teach- 
ing of self help and first aid be "augmented, modernized, and standardized" 
on a navy-wide basis. This navy-wide training program is based on the 
philosophy that first things come first; training is first at every level and, 
for an effective. passive defense plan, first aid and self help training is 
Tonquestionably first. 

The Navy Medical Department, in common with the medical services 
of the Army and the Air Force, recognizes its debt to its Reserve Medical 
officers. World War H and the Korean conflict brought many back to active 
duty where their skills in the various specialties contributed immeasurably 
to the fine record made in conserving life and health in the Arnjed Forces. 
The excellent way in which they performed, their fine devotion to duty and 
to humanity in general will always be a lasting tribute to military medicine, 
to the nation, and to themselves. 

The importance of the Reserve Medical officer is fully recognized and 
is no less now than in the past. As a matter of fact, the need for the Reserve 
has perhaps never been greater than it is now because of the part he will be 
called upon to play if nuclear warfare is ever loosed upon the world. 

Yearly, the race for weapons supremacy proceeds unabated. The 
weapons are designed for total warfare, the characteristics of which have 
never been experienced and can only be imagined. Survival will become 
of primary importance — not only national survival, but racial survival. 
To survive in this country, there must be medical pre-planning. That is 
why Reserve Medical officers are more important now than ever before. 
Their training in organization, logistics, and combat experience will be 
invaluable qualifications. 

The author urges all who belong to organized units to take an active 
part in the medical preparedness planning for disaster in their communities. 
Reserve units so engaged have effected excellent liaison with all Armed 
Forces within their areas and have added to the strength and security of 
planning which must be between civilian and Armed Forces to effect an 
adequate program for the nation. 

The more tangible needs for the Reserve Medical officer is in med- 
ical disaster planning for local disasters in his cominunity. The Bureau of 
Medicine and Surgery is cognizant of the capacity. It is urged that those 
who have not participated enter this field of community service for which 
the Armed Forces have prepared them. In this way, another link to the 
chain that affects the defense and security of the nation can be forged. 
(RADM B. W. Hogan MC USN, The Surgeon General, Medical Problems 



Medical News Letter, Vol. 33, No. 7 



of Modern Warfare and CivilDisaster: IZth. Naval District Symposium, June 

19 58 -Introduction to tie Problems, J. Arizona M. A. , 16 : 109-1 15, February '59^ 

****** 
Ectopic Pregnancy 

Fifty consecutive cases of ectopic pregnancy, 48 tubal and 2 ovarian, 
observed at Tripler U. S. Army Hospital during 1956 and 1957 are presented. 
An attempt is made to correlate the several diagnostic procedures with, 
accuracy in reaching the diagnosis and to emphasize the pitfalls along the 
way to correct definitive treatment. It is believed that an «inalysis of all 
patients in whom the diagnosis was entertained at initial examination, and of 
all in whom the diagnosis was not suspected but proved after further obser- 
vation, is of value. These cases occurred in dependents of military per- 
soiuiel and were handled completely by the resident cind teaching staff of a 
large military hospital. 

Ectopic pregnancy is by definition any pregnauicy which occurs outside 
the uterine cavity where implantation of a fertilized ovum would ordinarily 
take place. This includes a pregnancy in the uterine comu, the cervix, the 
Fallopian tube, or outside the Fallopian tube in the abdominal cavity, the 
ovary, or the cul>de-sac. The most common site for an ectopic pregnancy 
is in the Fallopian tube. Consequenily, ectopic pregnancy is usually assoc- 
iated with, or thought of, as a tubal pregnancy. 

In this series there were 48 tubal pregnancies and 2 pregnancies in 
the ovary, all of which were proved by histologic examination. The 2 ovarian 
pregnancies, however, did not fulfill the criteria set forth by Spiegelberg. 
In each instance, both tubes appeared normal at the time of laparotomy and 
were not removed. The etiology of the bleeding was felt to be a ruptured 
corpus luteum cyst which was resected. Both of the surgical specimens, 
however, at the time of histologic examination were found to contain tropho- 
blastic villi within the stib stance of the ovary. 

The diagnosis of ectopic pregnancy depends a great deal on the history 
and physical examination. Three outstanding signs or symptoms were pres- 
ent in the history of these patients; (1) abdominal pain« (2) vaginal bleeding 
either before or at the time of admission, and (3) a period of amenorrhea. 
Forty-nine patients had as their chief complaint abdominal pain, either 
generalized or localized. The only other patient was admitted for an elective 
laparotomy for pelvic Inflammatory disease and was found to have an inciden- 
tal ectopic pregnancy as well, A history of vaginal spotting either prior to, 
or at the time of, admission was significant. Forty-five patients had a period 
of amenorrhea exceeding 4 weeks and in most cases some form of abnormal 
menstrtial history. The abdominal pain in most cases was rather severe. 
Although most patients complained of generalized lower abdominal pain, 28 



10 Medical News Letter, Vol. 33, No. 7 



could, localize the pain to either the right or left lower quadrant. Of the 38 
patients with vaginal bleeding, only 15 were found to have bleeding on ad- 
mission, while 22 patients had had vaginal bleeding one or more times 
prior to admission. In most cases, this bleeding'was described aa snsall 
in amoxmt, definitely different from that of a normal menstrual period. 

A history of amenorrhea was present in 90% of this series. There 
were only 5 patients who did not have a period of amenorrhea of at least 4 
weeks. The average length of amenorrhea in the entire series was 6 weeks. 

All patients in this series except the one with the incidental ectopic 
pregnancy were found to have abdominal tenderness on physical examination. 
Thirty-seven patients had definite rebound tenderness indicative of peritoi 
neal irritation. Associated with the rebound tenderness, but to a lesser 
degree, were the findings of abdominal rigidity eind abdominal distention. 
As expected, the pelvic findings were most significant. The cervix was 
visualized in all patients. Over one-half had a positive Chadwick's or 
Hegar's sign and an equal percentage had a tender uterus, especially on 
tnotion of the cervix. Only 15 patients had a definitely enlarged uterus 
which might lead one to suspect an intrauterine pregnancy rather than an 
ectopic gestation. On bimanual examination, however, two-thirds of the 
patients had a definite palpable adnexal mass, tenderness of the cul-de-scic, 
or cul-de-sac fullness. One or more of these findings are significant in 
noaking the diagnosis of ectopic pregnancy. 

Shock or impending shock (rapid pulse and pallor) was found relatively 
infrequently in this aeries. Only 10 patients presented with clinical shock 
while an additional 21 were found to be quite pale frotsa blood loss either 
chronic or acute. This was slightly unusual in view of the fact that 74% of 
the patients were found at the time of operation to have a ruptured tubal 
pregnancy. The average blood loss for this series was likewise approx- 
imately 700 cc. per patient. 

The treatment of ectopic pregnancy is surgical. Cxcision of the 
affected tube or pregnancy site with preservation of as much functioning 
tissue as possible, especially the ovary, is important. This is usually an 
emergency procedure and should be performed as quickly as possible and 
without additional elective surgery. In the face of gross bleeding, it is poor 
technique to undertake an appendectomy or removal of an infected salpinx 
from the opposite side for fear of peritoneal spill in the face of an excellent 
culture medium. Once the diagnosis of ectopic pregnancy is made or there 
is a strongs suspicion of it, the surgical treatment should be carried out 
through a laparotomy incision. 

The authors believe that transfusion is second only to operation in 
reducing maternal morbidity £ind mortality. After a study of the charts of 
all patients in this series, the calculated average blood loss was found to be 
approximately 650 to 700 cc. Blood transfusions were accurately recorded 
in all cases and the average blood replacement for the entire series w as 



Medical News Letter, Vol. 33, No, 7 11 



850 - 900 cc. of blood. Thirty patients, or well over half of the series, 
reqiiired at least 500 - 1000 cc. of blood. Twenty-six patients, or over 
50%, received 1000 cc. or more of whole blood. Blood was given in all 
cases by the intravenous route. In many cases, this was given at a rapid 
rate under pressure. In none of the cases was it felt necessary to give 
intra -arterial transfusion. Of the 8 patients who required no blood replace- 
ment, 3 had unruptured tubal pregnancies, 3 underwent operation within 4 
hours of admission and were believed to have less than 500 cc. of blood in 
the abdominal cavity, one was taken to the operating room within 24 hours 
of admission and was found to have a well -confined rupture within the broad 
ligament, and one patient was operated on during the third hospital day amd 
found to have a well-localized, but ruptured, tubal pregnancy. All patients 
who were clinically in shock or had very low hematocrits were started on 
blood replacement prior to anesthesia. In nearly all cases, blood replace - 
naent was given during the operative procedure. 

The morbidity is not recorded strictly according to the standard of the 
Am^erican Committee on Materhal Welfare. The patients were dividedintb 
two groups: (1) those who at no time during their hospital stay had a tem-: 
perature elevation above 99° F. , and (2) those who had a temperature over 
100*^ F. on one or more days during their hospital stay. Thirty-five patients 
(70%) fell in the second group. In most cases, the elevation of temperature 
did not persist for more than 24 to 36 hours eind was believed to be due in a 
large number of cases to a foreign body reaction, absorption of blood from 
the peritoneal cavity. In this group, there were 2 cases of postoperative 
pneumtmia, 2 urinary tract infections, one case of diarrhea with etiology 
undetermined, one wound infection, and one mild transfusion reaction. The 
average hospital stay for the entire series was 8 days. There were 23 
ptatients treated with antibiotics postoperatively. All of the mentioned post- 
operative complications were treated with antibiotics. The authors do 
not believe that antibiotics shoxild be used prophylactically in all ectopic 
pregnancies, but certainly believe that they will reduce the severity of 
complications when indicated. The antibiotics used in most cases were 
penicillin and streptomycin unless a specific organism was isolated which 
was sensitive to a speci£.c antibiotic. Of the 4 patients in whom an inciden- 
tal appendectomy was done at the time of laparotomy, 2 ran a temperature 
above 100*^ F, during the postoperative course. None of the 4 were given 
antibiotics. Two patients had some difficulty postoperatively with abdom- 
inal distention, one of whom required Wangensteen suction for approximately 
24 hours. Patients who have a large amount of blood in the abdomen usually 
develop postoperative ileus no matter how gently the operation is performed 
or how little the pelvic organs are disturbed. 

There was no maternal death. Prior to 1940, the percentage of mater- 
nal deaths frona ectopic pregnancy has been reported from 3 to as high as 

12%. More recently, the mortality rate has dropped to from 1 to 3%. —— 

(CAPT F. L. Soisaon USAF (MC), CAPT J. P. Moran MC USN, Ectopic 



12 Medical News Letter, Vol. 33, No. 7 



Pregnancy - A Review of Fifty Cases at Tripler U. S, Army Hospital: Am. 
J. Obst. k Gynec, 77:352-362, February 1959) 

3(C 4c )|E S|C itC ^ 

Acute •Granulocytic JLetikemia in Pregnancy 

Acute leukemia in pregnancy poses a delicate tkerapeutic problem 
because the very agftuts which are ordinarily most effective in antileu- 
kemic therapy may seem contraindicated by virtue of their potential del- 
eterious effects on the fetus. Both folic acid antagonists and purine analogs 
are capable of inducing abortion and developmental anomalies if administered 
early in gestation. For this reason, and because a major aim of therapy in 
such cases is generally to secure normal progeny, there is considerable 
sentiment in favor of the antimetabolites in the management of acute leukemia 
during pregnancy. In a recent comprehensive review of the subject, it was 
maintained that corticosteroids are the drugs of choice in acute leukemia 
during pregnancy with antimetabolites reserved for patients in whom steroid 
control fails. 

Cases in this review are presented chiefly to illustrate that corticos- 
teroids also may have their drawbacks in tlie therapy of acute granulocytic 
leukemia in the pregnant patient, and that therapy with an antimetabolite may 
be carried out with safety and a favorable result. 

interpretation of factors affecting the outcome of a particular case of 
acute leulcemia may be difficult because of the poor prognosis and fatal out- 
come of all cases. £ven with optimal therapy, the median life span of adiilts 
with this disease is but 7 months and only 10% of patients live as long as 16 
months; it is not surprising that during the 9 months of pregnancy with all 
its attendant stresses most women with acute leukemia succumb. Yahia, 
Hyman, and Phillips have tabulated cases reported in the English literature 
between 1944 and 1956. Of 20 pregnant patients whose acute leukemia appeared 
in the first or second trimester, only 8, or 40%, were able to survive the preg- 
nancy and most of these patients died shortly thereafter. The median survival 
time of these 20 patients was about 5 months, a figure which is probably not 
significantly different from that of nonpregnant patients in the same age group. 
Thus, there is little effect of pregnancy per se upon acute leukemia, except 
that few women with the disease are able to survive the normal period of 
gestation. 

One might also inquire as to the effect of the leukemia on the pregnancy. 
The high maternal mortality is due to the major terminal complications of 
leukemia, namely infection and hemorrhage. Premature labor is common, 
and prematurity is a principal cause of the high fetal mortality. Excessive 
postpartum hemorrhage occurred in 6 of the 32 cases tabulated by Yahia, 
Hyman, and Phillips. The fetal mortality in their series was 39% 



Medical News Letter, Vol. 33, No. 7 13 



In view of the dismal outlook for the pregnant woman with acute leu- 
kemia, it is understandable that patients with the disease are usually dis- 
couraged from becoming pregnant. However, occasionally pregnancy will 
occur. More commonly, onset of pregnancy antedates the onset of leukemia. 
In either circumstance, the physician's aims in management may be governed 
to some extent by social and psychological factors peculiar to each case. Cer- 
tainly, on purely physical grounds there does not appear to be any justification 
for therapeutic abortion in most cases. In general, the aim of therapy is to 
sustain the pregnancy long enough to permit pelvic delivery at term and the 
birth of a healthy infant. Caesareaji section should be reserved for sittiations 
in which the mother is moribund or for fetal distress in the presence of a 
viable gestation. 

It appears that in acute grajiulocytic leukemia in pregnancy, a pref- 
erence for therapy with corticosteroids rather than 6-mercaptopurine cannot 
be justified on grounds either of greater safety for the fetus or of greater 
likelihood of maternal benefit. The authors believe that by virtue of its more 
fulminating character and more immediately fatal prognosis, acute leukemia 
provides a different problem in management from certain other hematologic 
neoplasms. In Hodgkin's disease and in chronic leukemia, prognosis of the 
pregnancy is usually good and because of the potential harniful effects of 
cytotoxic agents, their use should be avoided whenever possible. Where 
therapy is urgently needed, minimum doses required to achieve the desired 
result shovild be employed; in almost every such case, therapy can and should 
be deferred until after the first trimester. In acute leukemia, on the other 
hand, prognosis is poor and few mothers can sustain a normal pregnancy. 
If a viable infant is desired, the only hope is to treat the leukemia vigorously 
with the aim of producing a remission or suppressing the disease for long 
enough to allow the pregnancy to reach term. At the present time, the agent 
most likely to achieve this end is probably 6-mercaptopurine. 

In the meinagement of acute leukemia in pregnancy, steroids are not 
necessarily superior to antimetabolites. The best over all therapeutic reg- 
imen is that which is most effective against the leukemia itself. (H. Rothberg, 
M. D. , CAPT M. E. Conrad MC USA, LTCOL R. G. Cowley MC USA, Acute 
Granulocytic Leukemia in Pregnancy - Report of Four Cases with Apparent 
Acceleration by Prednisone in One: Am. J. Med. Sci. , 237 : 194-203, February 
1959) 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget, 19 Jtme 1958. 

sfc sic sic sic sfe iSt 



14 Medical News Letter, Vol, 33, No. 7 



Periureteric Fibrosis 

Periureteric fibrosis, an idiopatiiic retroperitoixeal fibrotic process, 
is a recently recognized disease characterized by unilateral and bilateral 
ureteral obstruction. This report describes certain clinical and radio- 
graphic features observed in four cases of periureteric fibrosis studied at 
the Massachusetts General Hospital. It is hoped that the observations may 
facilitate the early diagnosis of this rare syndrome. 

Periureteric £.brosis is a progressive process involving the retro- 
peritoneal tissues. Raper suggests that it originates in the region of the 
great vessels, while Chisholm believes that it takes its origin from the 
fascia of the psoas muscle. It has been found in a case of periarteritis 
nodosa. It is known that regional ileitis, appendicitis, cmd diverticulitis 
are inflammatory processes capable of producing ureteral obstruction. 
Chisholm and associates suggested that, in their patients, infection in the 
retroperitoneal space which encloses the aorta, inferior vena cava, and 
the urinary tracts, could produce the fibrotic changes. In many reported 
cases, however, evidence of inflammation is absent. Whatever its origin 
may be, it is known that the fibrotic process extends from the kidneys to 
the sacral promontory, spreading laterally to involve one or both ureters. 

The cut surface of the fibrotic lesion ia grayish -white, its appearance 
being similar to that of metastatic carcinoma or lymphoma. Microscopically, 
the process shows an actively sclerosing type of inflammatory fibrosis infil- 
trated withmonocytes, lymphocytes, and some eosinophils. Culture for 
organisms is negative. 

A good history is usually the key to the diagnosis of any disease. Peri- 
ureteric fibrosis is no exception. Pain, initially vague in character, is the 
chief presenting symptom. It has been described as an indefinite backache, 
a gnawing feeling, or a dragging discomfort in the lower quadrants of the 
abdomen, changing later to a cramp-like pain radiating into the genitalia 
or thighs. The pain becomes worse on lying down. Sometimes, it is re- 
lieved by lying prone or in the "doubled over" position as described by one 
patient. Usually, slight abnormalities in the urine, occasional red and white 
blood cells, and slight elevation of the white blood cell count are the only 
laboratory changes noted. Fever is absent. The patients with anuria present 
with various signs and symptoms of uremia with abnormalities in the urine 
and elevation of the serum non-protein nitrogen or urea nitrogen. The phys- 
ical signs and laboratory tests are unremarkable; nevertheless, they con- 
tribute something by their very normality. This is particularly evident in 
cases of unilateral obstruction. 

Plain films of the abdomen — the first step in a radiologic examination — 
may show disappearance of the normal fat lines which outline the various 
retroperitoneal stmctures, notably the psoas and lumbosacral muscle. 



Medical News Letter, Vol. 33, No. 7 15 



This abHence of fat planes may assist in identifying a mass of inflamma- 
tory tissue obscuring these retroperitoneal structures. 

Intravenous urography is the prime radiographic procedure which 
demonstrates the abnormality in the urinary tracts. There may be delayed 
excretion of the contrast material, dilatation of the major and minor calyces 
and/or the kidney pelvis, or complete urinary obstruction on one or both 
sides. If the obstruction is apparent, the contrast material gradually tapers, 
demonstrating a local narrowing of the ureter. The actual cause of the ob- 
struction may not be evident. This may best be demonstrated by retrograde 
urography. Despite the degree of obstruction, a catheter maybe passed 
beyond the point of narrowing, sometimes with remarkable ease. This is 
not always possible, however. Insertion of the catheter to the point of 
obstruction and injection of the opaque substance may be the most definitive 
diagnostic procedure. The ureter above the point of obstruction is dilated, 
the dilatation ending in a smooth cone-like narrowing, tapering gradually 
into an irregular isthmus which is fixed in position and whose diameter does 
not vary. The narrowed segment may be 3-4 cm. in length. 

The early recognition and diagnosis of ureteral obstruction caused by 
periureteric fibrosis are most important for surgical relief of the obstruc- 
tion produced by the Insidious creeping of the fibrotic process which may 
eventually involve both ureters and thereby produce anuria. Retroperitoneal 
air insufflation may supplement the urographic studies in establishing the 
presence of retroperitoneal disease. Observation of the peristaltic activity 
of the ureters by means of fluorography or cinefluorography may contribute 
to the knowledge of the pathologic physiology of the involved segment of 
ureter and help explain the apparently paradoxical ease of retrograde cath- 
eterization. 

The absence of a mechanical obstruction to the passage of a ureteral 
catheter in the presence of anuria suggests the possibility of retroperitoneal 
malignant infiltration. To distinguish this from periureteric fibrosis is 
difficult if not impossible. A nonopaque ureteral calculus or blood clot can 
produce ureteral obstruction and sub stcinti ally the same roentgenographic 
findings. 

Various procedures have been used to alleviate the symptoms and 
signs of ureteral obstruction. Antibiotics with indwelling catheters which 
were later removed from the ureter engulfed in the fibrotic process have 
been used with success. Other methods of treatmient include ureterolysis 
and placing the ureter free in the abdominal cavity, bilateral nephrostomies 
with ureteral dilatation, nephrectomy, auid radiation therapy. Ureterolysis 
is probably the treatment of choice. (Millard, D. G., Wyman, S. M. , 
Periureteric Fibrosis - Radiographic Diagnosis: Radiology, 72; 191-195, 
February 1959) 

sk ■&£ 9&C 93c 4c ^ 



16 Medical News Letter, Vol. 33, No. 7 



Treatment of Scleroderma 

Scleroderma or diffuse systemic sclerosis is a challenging disease. 
Its etiology is not known and its pathogenesis is poorly understood. The 
clinical and histopathologic features of scleroderma have been repeatedly 
described and are mentioned only briefly in this review. 

Characteristically, there is cutaneous involvement, usually ushered 
in by an acute edematous phase followed by induration and atrophy. Raynaud's 
phenomenon may precede, accompany, or, rarely, follow the onset of objec- 
tive skin change. Pain and stiffness of joints and myalgias are not uncommon. 
Although the changes in the skin may dominate the clinical picture, it is n$w 
well known that no system is immune. Diffuse sclerosis may proceed through- 
out the body wherever there is tissue of mesenchymal origin. Thus, changes 
may be induced not only in subcutaneous structures, but also in the various 
muscles, blood vessel walls, esophagus ajid gastrointestinal tract, the luiigs, 
heart, and kidneys. Much of the involvement of organs is manifested by 
fibrotic changes in the smooth muscle coats, for example, in the musculat>is 
interna of the esophagus and bowel, or about arterioles. Signs of nonsuppura- 
tive inflammation are often found in addition to sclerotic changes. 

Such profound structural alterations in tissue inevitably give rise to 
disturbances in function of the organs and often to severe contractures of 
involved joints. Fibrotic tissue, by its very nature, \indergoes shortening 
and thereby causes progression of contraction deformities and atrophic 
changes. 

In view of the type and extent of involvement, it is not surprising that 
fully developed scleroderma causes profound disability and is associated 
with a high fatality rate. Treatment has necessarily been empiric and many 
and varied forms of therapy have been advocated. None has been uniformly 
successful and satisfactory. Nevertheless, it is believed that much can be 
accomplished if antifibrosis therapy is Instituted early and available meas- 
ures to prevent disabling contractures are fully utilized. The therapeutic 
program described is directed toward these ends. It has evolved from 
experience accumulated during the last decade in the management of 72 cases 
of scleroderma, together with information concerning 10 other patients who 
were treated in a similar manner. There was no selection of patients admitted 
to this series, each being placed on the program regardless of the severity of 
the disease. Some had previously undergone cervical sympathectomy; others 
had been treated with corticosteroids, ACTH, testosterone, Bistrimate, and 
other substances without evident benefit. There were 14 males and 58 females 
in this series Fcinging in age from 3-1/3 to 75 years at the time of institution 
of therapy. The earliest onset was at the age of 10 months in a female child 
who also exhibited phenylpyruvic oligophrenia. 

The program followed in the management of the patients in this 
series consisted of (1) systemic antifibrosis therapy through the long-term 




Medical News Letter, Vol. 33, No. 7 17 



administration of potassium para-aminobenzoate; (2) physiotherapy includ- 
ing dynamic traction splints where applicable; and (3) Urecholine for the 
alleviation of dysphagia. 

Some 10 years ago, potassium para-aminobenzoate (Potabe, KPAB) 
was first observed to soften and reverse in varying degree the cutaneous 
changes of scleroderma. At that time, large doses of the drug were 
administered to a 40 -year old man who exhibited features of both dermatQ- 
myositis and scleroderma. Striking improvement occurred in both com- 
ponents of his illness and this led to the further use of Potaba in the treat- 
ment of scleroderma. 

For administration to patients, potassiuin para-aminobenzoate has 
been fovmd to be preferable to the crystalline acid or the sodium salt. The 
potassium salt is leas frequently associated with anorexia and nausea. Like 
other potassium compounds, KPAB is best given in liquid form. Patients 
generally prefer a chilled 10% aqueous solution of KPAB to other prepara- 
tions. Capsules are often well tolerated, but tablets not infrequently cause 
abdominal cramps. 

The case reports along with data in a Table clearly indicate that the 
long-term administration of Potaba in adequate dosage will produce mod- 
erate to marked iniprovement in the great majority of scleroderma patients. 
It is recognized that Potaba is not a complete treatir.ent for scleroderma. 
In the highly active, rapidly progressive form of disease, Potaba may only 
retard the process. 

Untoward reactions have been documented elsewhere. These consist 
mainly of gastrointestinal complaints, such as anorexia and nausea which 
will subside after omission of the drug for a day or so. Treatment may 
be resumed as soon as the patient is eating well. By interrupting therapy 
during periods of poor dietary intake, the development of hypoglycemia 
may be prevented. Scleroderma patients with dysphagia may also occas- 
ionally note a burning sensation after swallowing a dose of the medication. 
This is usually relieved by antacids or milk. 

These effects are not considered to be true toxic reactions. Indeed, 
Potaba is remarkably free from toxicity in doses employed in these and 
related studies. A few instances of drug rash and fever have been encoun- 
tered, especially in lupus erythematosus patients. Leukopenia may at 
times be encovintered during KPAB therapy, but its significance is difficult 
to assess because there is often a return to normal values despite continued 
administration of the drug. In more than 500 patients treated in this and 
other studies, no agranulocytosis has been encountered. 

The mechanism by which Potaba mediates its effects in scleroderma 
has not been elucidated. However, recent studies appear to bear directly 
on this point. 

Attention is drawn to another major difficulty in the management of 
scleroderma, namely, pericapsular fibrosis and joint contractures whjdl 



18 Medical News Letter, Vol. 33, No. 7 



ensue from this process. In addition, it is shown that there is a similar 
involvement of the articiilations of the thoracic cage; this may lead to rigid- 
ity of the thorax and embarrassment of ventilatory function. It is of the 
greatest importance that physiotherapeutic measures, including deep 
breathing exercises, should be started early ^and maintained indefinitely 
in patients with scleroderma. The supplemental use of dynamic traction 
splints has been particularly valuable in dealing with contractures of the 
hands . 

Many scleroderma patients complain of dysphagia and show evidence 
of a deranged esophageal transport mechanism. Urecholine affords relief 
to these individuals. 

It should be recognized that a chronic disease, such as scleroderma, 
will require chronic treatment. In the absence of specific therapy for this 
disease, any program of nnanagement which is followed should be safe for 
long-term use, should be practical, smd should be economically feasible. 
It is believed that experience with the therapeutic regimen described indi-r 
cates that it conforms to these requirements. (Zarafonetis, C. J. D, , 
Treatment of Scleroderma: Ann. Int. Med., 50:343-364, February 1959) 

****** 

K ehabi litation 

Medical rehabilitation forms the fourth phase in the over all scheme 
of health and medical measures applicable to an individiial or to a community; 
namely, the promotion of health, the prevention of disease, the treatment of 
disease, and medical rehabilitation. In the planning of health and medical 
services, emphasis should be placed upon the prevention of diseases and in- 
juries which are liable to lead to permanent disabilities requiring rehabili- 
tative measures. 

Rehabilitation contributes to the achievement of health by: 

1. Preventing the development of unnecessary disability during the 
treatment of illness as illustrated by the stiffness and wasting associated 
with immobilization, or the anxiety occasioned by lack of prompt reassur- 
ance about the medical, social, and vocational consequences of disease or 
injury. 

2. Assisting those afflicted with unavoidable disability, such as congen- 
ital deformity, accidental loss of sight, or incurable disease, to achieve 
the fullest physical, mental, social, and vocational usefulness of which 
they are capable. 

The rehabilitation process is a complex one, involving several dis- 
ciplines and different techniques working together as a team in order to 
achieve the best end-results for the handicapped person. The team approach 
must be emphasized because no single discipline or technique could accomplish 



Medical News Letter, Vol. 33, No. 7 19 



the desired objective to the exclusion of the others. Thus, medical rehab- 
ilitation must come first to restore or resuscitate the remaining, dimin- 
ished, or disturbed physiological and psychological functions of the handi^ 
capped person. 

During or shortly following the medical rehabilitation, the educational, 
vocational, and social aspects of rehabilitation should be initiated. The 
entire process of rehabilitation should provide for a smooth and continuou;s 
operation from the onset of sickness or injury until rehabilitated. 

Progress in medical science has led to the prevention of many dis- 
eases; however, it has created new problems in rehabilitation because 
severely disabled patients who formerly died now survive. At the same 
time, economic, industrial, and social progress has raised the educational 
and vocational standards which the disabled must attain if they are to hold 
their own with the able-bodied. Thus, in a highly developed society, mai»jr 
services may be concerned in the total rehabilitation of an individual patient, 
but unless there is close integration and teamwork the desired result will 
not be attained. 

General Aims and Principles 

The basic aim of medical rehabilitation is not only to restore the dis- 
abled person to his previous condition, but to develop his physical and mep- 
tal functions to the maximum. More specifically, the aims of medical 
rehabilitation are not only "physical cure" but "social cure. " For example, 
the individual must be restored to his former job, prepared for any full-time 
employment, prepared for part-time sheltered employment — in other words 
to self-reliance in daily life. 

Regardless of the goal, attention should be directed to the large phys- 
ical and mental resources upon which the disabled person can draw. The 
individual should be treated as a whole and not as an assortment of organs 
and extremities. Emphasis then should not be on the individual defects, 
but on the remaining assets and their reintegration into a total effective 
dynamic pattern. ,^ 

The physical restoration of the sick, injured, or disabled person will 
depend on his constitution, the application of all accepted medical and sur- 
gical procedures, and the complementary or supplenaentary use of all 
physical measures. 

Treatment should begin early to avoid the deleterious effect of pro- 
longed immobility resulting in loss of muscle tone, atrophy, and metabolic 
deficiencies and psychological disturbances. 

Principles of Therapeutic Application 

Many illnesses normally proceed to rapid and complete cure with 
medical and nursing care alone, and in such cases no other services may 
be required. In certain acute illnesses and injuries, especially tho se -w hich 



20 Medical News Letter, Vol. 33, No. 7 



might result in Impairinent, chronic diseasesj or disabilities, the doctor 
needs the kelp ajid collabo ration of a team of nurses, physical therapists, 
occupational therapists, prosthetists, medical social workers, and other 
paramedical personnel. 

Physical measures employed in the treatment of injury and disease 
have had long history. Traditionally, they consist in the use of such phys^ 
ical agents as heat, electricity, massage, water, and exercise. While all 
these agents have a place in physical restaration services, the greater 
emphasis in the past two decades has been on exercise in its various form^, 
such as group exercises and remedial games. Neurophysiological research 
has demonstrated the value of developing muscle power, range of motion of 
the joints, and coordination of muscles in group patterns rather than by 
single muscle treatment. 

Physical therapy associated with occupational therapy aims at restor- 
ing impaired function through the use of craft and industrial activities, 
thereby develoixLng the ability to carry out the needs of personal self-care* 
such as eating and dressing, as well as restoring the capacity to work. There, 
fore, consideration should be given to the development of those activities 
which would be applicable to the needs of independent living and capacity t^ 
work. 

The whole range of prosthetic devices; namely, artificial limbs and 
eyes, sensory aids (hearing devices), and self-help devices (adapted equip- 
ment, crutches, braces, wheelchairs, and automobiles) is an important 
part of the armamentarium of rehabilitation services. All prosthetic appli- 
ances should be made to the patient's measurements and individually fitted. 
Artificial limbs, wherever prescribed, should be considered as a part of a 
coordinated program which includes: 

1. Full psychological preparation and orientation of the 

patient 

2. Adequate surgery 

3. After-care of the stump 

4. Prescription, fabrication, fitting, and servicing of 

prosthesis 

5. Training in the use of prosthesis 

Many rehabilitation services can be adequately carried out in hos- 
pitals and hospital departments. However, the greatest efficiency can be 
achieved by grouping these comprehensive services in a rehabilitation cen- 
ter. The rapid developnient of these centers throughout the world is evi- 
dence of the effective manner in which these needs are being met. 

Needs 

Rehabilitation services deal, broadly speaking, with three types of 
cases. The first type is the patient who, after a period of medical or sur- 
gical care with physiotherapy, remedial gymnastics, and other paramedical 



Medical News Letter, Vol. 33, No. 7 21 



procedures, can return to his normal work and normal life. The second 
type is the patient with a stable disability which is of such a degree or natifcre 
that it will permanently influence his life and will, therefore, demand that 
in addition to the specific rehabilitation services, the patient will also need 
educational, vocational, and social help. The third type is the patient whote 
disability is either progressive or liable to vary in degree and effect from 
time to time. This patient needs the kind of total service which is given to 
the second type of patient, although after his resettlement in work he may 
continue to need help from one or niore of the services, either regularly 
or intermittently, for the rest of his life. To distinguish between type two 
and type three is not easy. The patient who has been rehabilitated and re- 
settled in work different from that which he formerly did or who has had to 
return to his normal work and normal life with a handicap cannot be finally 
regarded as reestablished until he has had a substantial period during which 
to adjust to his new circumstances. Sometimes, such a patient may have 
persistent difficulty in adjusting and may, therefore, need the continuing 
help which is given to the type three patient. 

It has been said that rehabilitation begins when the patient enters the 
hospital door and ends only when he is successfiilly and happily reestablished 
in society. The process which brings this about involves four main groups of 
services: medical, educational, vocational, and social. (Abstract: Expert 
Committee on Medical Rehabilitation, First Report, WHO, 1958) {OccMed- 
EdspDiv, BuMed) 

Air Pollution - A Menace to Public Health 

One of the consequences of the industrialization of Europe has been 
the uncontrolled discharge into the air of increasing quantities of smoke, 
particulate matter, and waste gases. Since World War II, anxiety has been 
growing about the grave danger to public health represented by this constant 
pollution of the atmosphere. The World Health Organization (WHO), Regional 
Committee for Europe, discussing this problem at its 1955 session, came 
to the conclusion that a combined effort by the countries of Europe was re-^ 
qmred for its solution. 

As a first step towards implementing this recommendation, a Confer- 
ence on Public Health Aspects of Air Pollution was convened by WHO in 
Milan, November 1957. Twenty-one Europeain countries participated; 
the United States, the EuropeeUi Coal and Steel Commtmity, and the Organ- 
ization for European Economic Cooperation sent observers. 

The organizers of the Conference set up two working groups, one to 
study the sanitary and engineering problems involved in prevention of air 
pollution, the other to consider the public health amd administrative aspects. 



22 Medical News Letter, Vol. 35, No. 7 



These two groups subtnitted reports to the Conference and the problems re- 
quLring farther investigation were summariaed in plenary session. 

"Air pollution is not only a difficult problem; it is for several couatries 
a new problem. " This statement in the final report of the Conference epi- 
tomises the present situation. 

Several countries gave striking examples of ill-effects on man, ani- 
mals, and plants caused by air pollution. In Belgium, deaths from chronic 
bronchitis are higher in the industrial provinces of LiegCt Namur, and 
Hainault than in other provinces. In the United Kingdom, it is estimated 
that in the Thames Valley smoke -polluted fog was responsible for 3500 to 
4000 deaths in four days in December 1952, and that a similar but less severe 
incident in 1956 caused 1000 deaths in Greater London. The health of school 
children is reported to have been adversely affected in some districts of 
Poland where smelting and similar industries are concentrated. A shale-oil 
factory in Kvamtorp, Sweden, gives off roughly 12 tons of dust, 200 tons of 
stiifur dioxide, and 1200 cubic meters of hydrogen sxilfide in 24 hours. 
Fatigue and discomfort as well as minor illnesses and respiratory symptoms, 
including bronchitis, have been found to be more common among people living 
near the factory than in the rest of the pop%ilation. Harmful effects on plant 
life have also been observed in the neighborhood of this and other shale-oil 
factories, iron and copper works, phosphate factories, carbon bisulfide 
factories, sulfate cellulose plants, and electro -chemical factories. 

Pollution from fluorine compounds had svuch. serious effects on cattle 
in the Netherlands that some had to be slaughtered and in Germany animal 
losses have occurred in the neighborhood of factories releasing arsenic 
compounds and metallic dusts into the air. Animals and plants have suffered 
in the neighborhood of aluminum factories in Switzerland, while in Finland 
a sulfuric acid plant and some other factories have had to pay heavy com- 
pensation for damage to crops and material. 

The Conference was in general agreement on the reality of the dele- 
terious effects of air pollution on health, and that this is a wide field for 
further research into such questions as the relationship between air pol- 
lution and certain well known respiratory and infectious diseases, the 
occurrence of minor illness and discomfort following air pollution, and the 
positive value of fresh air in the maintenance of health. 

The Conference recommended that all countries should make systema- 
tic measurements of air pollution and that the apparatus used should be stand- 
ardized. While relatively simple procedures are of value in giving a general 
assessment of the degree of pollution in an area, well equipped centers with 
adequately trained staff are essential if a thorough study is to be made. It 
is important that those engaged in such work should have at their disposal 
information on the meteorological conditions at the time of measurement. 
The possible hazards of ionizing radiations in the air shoiiLd be borne in 
n]ind and routine measurements made. 



Medical News Letter, Vol. 33, No. 7 



23 



The Conference believed that, in spite of the present lack of basic 
knowledge about the nature, source, and allowable levels of pollutants, 
there is much that can be accomplished immediately. Public health per- 
sonnel, sanitary and chemical engineers, industrialists and workers in 
related fields — meteorologists, town planners, and architects — must be 
brought together to find the most satisfactory solutions to air pollution. 

The Conference was of the unanimous opinion that prevention is better 
than cure and that efforts should be concentrated on controlling pollution at 
the source. Identification, measurement, and control of a pollutant can be 
carried out most effectively at the point of production in the industrial plant 
or in the chimney stack before it reaches the outside air. 

Not only industrial effluents, but also the exhaust gases of motor 
vehicles contribute largely to atmospheric pollution, A recent study in 
Paris showed that in the summer months the fumes given off by motor 
vehicles accounted for 70% of the total atmospheric pollution. Therefore, 
it was gratifying for the Conference to learn that some motorcar manufac- 
turers are modifying their engine designs in order to lessen the amount of 
pollution caused. The use of devices such as catalysts, after-burners, 
and mechanical fuel regulators seems to offer considerable promise for 
the future. (Chronicle of the World Health Organisation, 12: 14-16, January 
1958) ~ 

sfe sSc 3^ 3&M sfe «3c 

IN MEMORIAM 



CAPT Thomas W. Bennett MC USN (Ret) 
CAPT Joseph G. Schnebly MC USN (Ret) 
CAPT Kenneth H. Vinnedge MC USN (Ret) 
CAPT WilHam H. Whitmore MC USN (Ret) 
CDR John S. George DC USN (Ret) 
CDR Benton V. D. Scott MC USN (Ret) 
LCDR Ottice R. Scheile MSC USN (Ret) 
LT Donald A. J. Hammond MSC USN (Ret) 
LT James L. Okel MC USN 
CWO Ernest W. Herrmann HC USN (Ret) 
CW02 Harry D. Slusher MSC USN (Ret) 



17 March 1959 

9 February 1959 
5 March 1959 

30 January 1959 

11 February 1959 
16 February 1959 

10 February 1959 
9 January 1959 

4 March 1959 

12 February 1959 
4 January 1959 






Please forward requests for Change of Address for the News Letter to: 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving f\ill name, rank, corps, and old and new 
addresses. 



24 Medical News Letter, Vol. 33, No. 7 



From the Note Book 

I. RADM B. W. Hogan, Surgeon General of the Navy, will attend the 
Medical Conference of the Surgeons General of the NATO countries at 
SHAPE Headquarters, Paris, France, 8-10 April 1959. Following the 
Conference, the Surgeon General plans to visit Naval Medical Activities in 
France, French Morocco, England, Spain, and Italy prior to his return to 
Washington. At the invitation of the Surgeon General of the Army, he will 
also visit U. S. Army Hospitals in Germany and Italy where Navy patients 
are hospitalized. (TIO, BoiMed) 

Z. The Royal Norwegian Navy's Chief Psychologist, CDH Per Jo rem, 
has begun a four-months' orientation and training visit to several continen- 
tal U. S. Naval Activities. Approved by the Chief of Naval Operations and 
arranged by the Bureau of Medicine and Surgery, CDR Jorem's visit will 
last until early July and will take him through all phases of the U. S. Navy's 
preventive psychiatry program. Partictilar emphasis will be placed on 
those aspects of the program pertaining to the selection of personnel and the 
rehabilitation of disciplinary offenders. (TIO, BuMed) 

3. The Navy received an Edinburgh International Film Festival certificate 
for a Bureau of Medicine and Surgery film, "Color Vision Deficiencies. " 
The Edinburgh Festival Is an annual event. The United States participates 
each year, sending an official delegate and representative films. Over a 
period of 15 years, the Navy has received about 34 national and international 
awards for its motion pictures. "Color Vision Deficiencies" (MN 8246) is 

a 20-minute, 16 mm. film with sound and color, made for the Navy in 1957 
by Audio -Productions, 630 Ninth Avenue, New York 36, N. Y. It is intended 
for Medical Department personnel who are responsible for color vision tests. 

(TIO, BuMed) 

4. A five-day conference for Chiefs of Nursing Service at continental 

U. S. Naval Hospitals has been approved by the Surgeon General for 4-8 May 
1959. The conference will be held at the Bureau of Medicine auid Surgery, 
Washington, D. C, "Administration of a Nursing Service for Improvement of 
Patient Care" is the theme of the meeting according to the Nursing Division 
of the Bureau. (TIO, BuMed) 

5. A 6-day postgraduate course for physicians primarily interested in 
Internal Medicine will be given 11-16 May 1959 by the Department of Med- 
icine, Johns Hopkins Hospital, and Johns Hopkins University School of 
Medicine, Baltimore, Md. 



Medical News Letter, Vol. 33, No. 7 25 



6. When a hospital is confronted with hospital>acquired staphylococcal 
infections, the extent of the problem should be determined by tabulating 
all infections related to hospitalization including those occurring in the 
immediate period following discharge of the patient. When an epidemic is 
present, all isolated coag\ilase -positive staphylococci should be bacterio- 
phage -typed to find the prevalent strain and to trace its possible source. 
(Am. J. Med. Sci. , February 1959; K. M. Schreck, M. D. ) 

7. Restoration of pulsatile blood flow in the lower leg is the objective of 
surgical treatment for segmental occlusive disease of the femoral artery. 
This objective has been reached in 86% of 317 patients treated by the bypass 
graft technique. (Surg. Gynec. & Obst. , March 1959; G.C. Morris Jr., 
M. D. , et al. ) 

8. A new concept of hypothe rmic analgesia for extracorporeal open heart 
surgery is presented. Except for a muscle relaxant, no other anesthetic 
adjunct was required to maintain surgical anesthesia during bypass. Fif- 
teen cases are reported with only one mortality. The technique is des- 
cribed. (J. Thoracic Surg. , February 1959; W, W. Musicant, M. D. , et al. ) 

9. Observations in 12 patients suddenly developing psychiatric and neuromus- 
cular symptonns have revealed evidence suggesting a relationship between 
these symptoms and a depletion of the total body magnesium. (Ann. Int. Med. 
February 1959; CAPT R. E. Randall, Jr., USAF (MC) et al. ) 

10. The importeince of artificial pneumoperitoneum as a diagnostic aid for 
upper intra-abdominal tnasses outside the gastrointestinal tract is discussed. 
The procedure is simple and without untoward effects. (Radiology, February 
1959: N.R. Canoy, M. D. ) 

11. A review is presented of 193 cardiovascular operations on cyanotic chil- 
dren. The mortality was 20%. In 164 operations on cyanotic children with 
potentially operable lesions, there were 19 deaths (11.6%). (J. Pediat. , 
March 1959; R. Ash, M. D. , et al. ) 

Medical Intelligence Reports 
(Med-3820tT3 

The attention of all Medical officers, particularly those serving at 
sea or on foreign shore, is invited to the requirements of Article 23-124, 
Manual of the Medical Department. Compliance with this article is of great 
importance to the Navy Medical Department and the Navy as a whole. 

(ProfDiv, BuMed) 



26 Medical News Letter, Vol. 33, No. 7 



Additional Personnel Assignments 

The Surgeon General has approved establishment of the following pos- 
itions in the Office of the Director, Medical Service Corps Division: 
Code 35E - Assistant for Women's Specialists Section officers 
Code 35F - Assistant for Podiatry officers 

These officer assistants will provide the Division Director with pro- 
fessional advice and assistance in procurement, career management, and 
effective utilization of members in the respective Sections of the Medical 
Service Corps, 

The positions will be filled by additional duty assignments of officers 
having primary duty in the Washington area. The first officers to be as- 
signed are: 

Code 35E - LCDK Elizabeth O'Malley MSC USN, Naval Hospital, 

Bethesda, Md. 
Code 35F - LCDR William H. Woolf MSC USNR, Naval Dispensary, 

Washington, D. C. 
Officers filling similar assignments are: 
Code 35B - LCDR John E. Rasmussen MSC USN, BuMed 
Assistant for Allied Sciences Section officers 
Code 35C - CDR Robert L. Henry MSC USN, BuMed 
Assistant for Optometry Section officers 
Code 35D - LCDR Solomon C. Pflag MSC USN, BuMed 
Assistant for Pharmacy Section officers 

(MSC DIV BUMED) 

:Ji :^ :(c :{c :^ :{( 

American Board of Obstetrics and Gynecology 

"Office of the Secretary: Robert L. Faulkner, M. D, 

2105 Adelbert Road 
Cleveland 6, Ohio 

The next scheduled examinations (Part II), oral and clinical for all 
candidates will be conducted at the Edgewater Beach Hotel, Chicago, 111. , 
by the entire Board from May 8 through 19, 1959. Formal notice of the 
exact time of each candidate's examination will be sent him in advance 
of the examination dates. 

Cam.didates who participated in the Part I Examination will be notified 
of their eligibility for the Part II Examinations as soon as possible. 

The deadline date for the receipt of new and reopened applications for 
the I960 examinations is August the first, 1959. Candidates may submit 
their applications at any time before that date and are urged to do so. " 



1 



Medical News Letter, Vol. 33, No. 7 27 



Trudeau School of Tuberculosis and 
Other Pulmonary Diseases 

The Trudeau School of Tuberctilosis and Other Pulmonary Diseases 
which will hold its Forty-Fourth Session, June 8 to 26, 1959, continues to 
provide an unique opportunity for training in the field of chest diseases. 
This annual postgraduate course, conducted under the auspices of the 
Trudeau Foundation and supported by the Hyde Foundation, is able to pro- 
vide outstanding instruction at a minimal tuition of $100 for a three weeks' 
session. Attendance at the Trudeau School carries with it some distinction 
as well as a thorough review for specialization in pulmonary diseases or for 
work in public health involving tuberculosis. 

Medical Corps officers with a background of Internal Medicine who are 
interested in attending the session should apply by submitting a written re- 
quest to the Bureau of Medicine and Surgery to arrive prior to 8 May 1959; 
Successful candidates will be provided TAD «ind Per Diem orders plus reim- 
bursement of the $100 tuition fee. (ProfDiv, BuMed) 

BUMED INSTRUCTION 6250. 7 IZ March 1959 

From: Chief, Bureau of Medicine and Surgery 

To: Commanders in Chief; Fleet amd Naval Force Commanders; 

Special Force and Type Commands; Administrative Commands 

and Units; Flotilla, Squadron, and Division Commanders -Ships; 

Warships, Minecraft, Amphibious, and Auxiliary Type Ships; 

Patrol Type Ships; Floating Drydocks; Service Craft; and Military 

Sea Transportation Service Commands 

Subj: Procurement of deratting or deratting exemption certificates by 
U.S. Naval vessels entering foreign ports 

Ref: (a) Art. 22-32, ManMed 

(b) Art. 22-37, ManMed 

(c) GO No. 20 

This instruction promulgates information regarding a procedure by which 
naval ships operating for periods exceeding 6 months in areas without 
available representatives of the United States Public Health Service may 
procure a deratting or deratting exemption certificate, and by which naval 
officers may issue such certificates in other areas. 

sGc 306 .^ sic 3{c 9k 



28 Medical News JLetter, Vol. 33, No. 7 




DEIVTAL ilKWly^ I SECTION 



Silver Amalgam 

This article on silver amalgam discusses various factors that contribute 
to the success or failure of amalgam dental restorations. Particularly im- 
pressive is the observation that approximately 56% of all amalgam feiilures 
are due to improper cavity preparation, and that approximately 40% result 
from contamination or faulty mcinipulation at the time of insertion. 

Points brought out in regard to the use of silver amalgam in restora- 
tive dentistry are: 

Cavity Preparation. Improper cavity preparation contributes to recur- 
rent caries and/or fracture and ultimately to amalgam failure. Common 
faults in cavity preparation include inadequate extension of cavity margins 
to immune areas, lack of provision for btilk of amalgam, inadequate reten- 
tive form, and improper cavosurface margins. 

Dimensional Change . According to ADA specifications, amalgam shotild 
expand between 3 and 13 microns 24 hours after its insertion. Slight devia- 
tions are not significant, but changes of greater magnitude can lead to adverse 
re suit s , 

Compress iv e Str e ngth . Present ADA specifications for amalgatn in- 
clude a compressive strength requirement of 35, 000 lbs. per square inch 
after 24 hours. During the first hour, only about 10 to 15% of the eventual 
maximum strength is attained. It is important, therefore, to instruct the 
patient to avoid excessive biting forces or to restrict himself to a liquid diet 
during the first few hours. 

Flow . The strength and flow of amalgam are closely related. Flow 
applies to the ability of a material to retain its shape tinder a constant load. 
Amalgam restorations with high flow values are thought to be more suscep- 
tible to failures, such as flattened contact points, overhanging margins, and 
slight protrusion from the cavity preparation. Undertrituration may raise 
the flow value to as high as 8%, twice the maximum permitted by the spec- 
ification. Flow is increased also when condensation pressure is inadequate. 

Alloy -Mercury Proportion . If excess mercury is used in the original 
mix, a higher percentage of mercury will be present in the final restoration, 
regardless of the pressure or technique used during condensation. Fifty 
percent residual mercury content is acceptable, however; above 55%, there 
is a dratnatic drop in strength. Once the alloy-mercury ratio is established, 
additional mercury should never be added. 



Medical News Letter, Vol. 33, No. 7 29 



Trituration . Trituration reduces grain size and removes superficial 
tarnish on each alloy particle. This permits ready attack of the alloy by 
the mercury. Inadequate trituration results in weak restorations subject 
to fracture and fraying of the margins. Proper trituration results in in- 
creased strength, smoother surface, and lower tendency to tarnish. Al- 
though increased mixing time decreases expansion, this is not clinically 
significant. Inferior properties resulting from underainalgamation are the 
real danger. 

Mulling a nd M oi sture Con tam ination Mulling does not injure the amal- 
gam, but should be done in a rubber dam to prevent moisture contamination. 
Zinc in the alloy reacts with moisture from the palm or from the cavity to 
liberate hydrogen gas. 1)1.18 produces pressure within the restoration and 
causes protrusion from the cavity, marked reduction in strength, and pos- 
sible pain. The use of the rubber dann is recommended to minimize the 
chance of contamination. 

Condensation. A common cause of marginal failure and recurrent 
caries is improper condensation of the an:ialgam. Increments which are 
either too wet or too dry should not be used. To prevent a laminating effect, 
it should be possible to work mercury to the surface throughout the packing 
procedure. Small rather than large incrennents permit better adaptation. 
Amalgam which stands too long before condensation retains a greater amount 
of mercury and suffers reduction in strength. Several mixes must be em- 
ployed for larger restorations. 

Carving. The amalgam can be carved within two minutes after packing, 
but the margins should not be burnished at this time. Burnishing draws ex- 
cess mercury to an area, weakening it and making it susceptible to tarnish 
and corrosion. 

Polishing . Proper polish not only improves the appearance and the 
marginal adaptation of the restorative, but minimizes clinical tarnish. 
Polishing should not be undertaken within 24 hours, and preferably not for 
several days. There should be no overhangs, and contact areas should be 
rounded. A bevel-type finishing bur is advantageous to prepare the occlusal 
surface for polishing. Final finishing is accomplished with amalgam brushes. 
Whiting and tin oxide produce the final high luster. There should be no ex- 
cessive heat to draw mercury to the surface during polishing. (Amalgam: 
Dental Clinics of North America, November 1958) 

Articles by Navy Dental Officers Abstracted 
in ADA Journal 

Of eight articles abstracted in the March 1959 issue of the Journal 
oi the American Dental Association, five were prepared and submitted by 



30 Medical News Letter, Vol. 33, No. 7 



Navy Dental Corps o£B.cer8. All of the articles appeared originally in the 
Journal of Oral Surgery, Anesthesia, and Hospital Dental Service. The 
authors and articles are: 

CAPT Walter Vf . Crowe DC USN Treatment of Zygomatic 

Fracture Dislocations 

CAPT Theodore A. Lesney DC USN Cervicofacial Actinomycosis: 

and A Postextractlon Complied - 

CDR Kimble A. Traeger DC USN tion 

CAPT John P. Jarabak DC US^N Use of the Foley Catheter in Sup- 
porting Zygomatic Fractures 

CAPT Raymond F. Huebsch DC USN Clinical and Histological Study 

of Alveolar Ostitis 

CAPT Louis S. Hansen DC USN Diagnosis of Oral Keratotic 

Lesions 

S^ S^ ^ ^ ^ !^ 

Dental Interns for Fiscal Year I960 

Eighteen Fnsigns (1925) Dental who are scheduled to graduate from 
dental school in June 1959 have been selected for participation in the Navy 
Dental Intern Program for the period July 1, 1959 to June 30, I960. These 
Ensigns will be appointed as Regular Navy Dental Corps officers upon accep- 
tance of this year of training. Those selected are: 

Brown, Allen Kenneth University of Washington 

Charlick, Richard Edwin University of Michigan 

Connole, Peter William Marquette University 

Crawford, Benton Earl Baylor University 

Daughtry, Max Berry Emory University 

Gourley, James Vincent University of Washington 

Hack, Maurice Charles, Jr. Loyola University (Chicago) 

Hanley, John Henry Temple University 

Hancock, Edwin Joe State University of Iowa 

Hart, Gerald Lee University of Michigan 

Johnson, James Irving Marquette University 

Koch, Robert Wayne Washington University (St. Louis) 

Nash, Larry Lee State University of Iowa 

Preece, Richard Golden Washington University (St. Lotiis) 

Smith, David Joseph State University of Iowa 



Medical News Letter, Vol. 33, No. 7 



31 



Tennyson, Uoyd Roger 
Weigel, Eugene John Jr. 
Williams, John Peter 



University of California 
Western Reserve University 
New York University 



9|e 3^ 1^ :^ ^ :{c 




RESERVE SECTION 



Annual Meetirtg of the AMA 

The American Medical Association will hold its annual meeting in 
Atlantic City, N. J. , 8 - 12 June 1959. The Section on Military Medicine 
will have three daily sessions during the afternoons of the 9th, 10th, and 
1 1th in Room A of the Convention Hall. 

The Chief of Naval Personnel has authorized retirement point credit 
for eligible Naval Reserve Medical Corps officers who attend these sessions, 
provided they register with the military representative present. 

The Section on Military Medicine will provide a discussion of the 
Military Disability Retirement problems for Regular and Reserve officers. 
In addition, there will be a presentation by the Honorable Frank B. Berry, 
M. D. , Assistant Secretary of Defense (Health and Medical). Also other 
prominent authorities will participate in presenting the following subjects: 

First Session 

Medical Problems in the Jet and Space Age 

Medical Investigation of Pan-American World Airways 

Crash on 8 November 1957 
Medicare 

Second Session 

Communication - A New Challenge 
Strike 

Act I - Reveille — Before and a few hours after 

Act II - Fatigue — The next few days 

Act III - Taps— Much later 



Third Session 

Some Aspects of Air Force Biodynamics Research 
Practice of Medicine in the -Antarctic 



32 Medical News Letter, Vol. 33, No. 7 



Atperican Optomytric AasociatJon - 
Annual A4^®^"^g 

The American Optometric Association will conduct its 62nd Annual 
Congress at the Statler- Hilton Hotel, Dallas, Texas, 28 June - 1 July 1959. 

Planned for presentation are foux daily sessions of the Military 
Optotnetry Section which will be devoted to military optometry under the 
chairmanship of officers of the Military Services. 

Attendance at these sessions affords an excellent opportunity for 
inactive Reserve Optometrists to be brought up to date on the latest devel- 
opments of Military Optometry. 

The Chief of Naval Personnel has authorized retirement point credit 
to eligible Naval Reservists who attend provided they register with the mil- 
itary representative present. 

The subjects to be presented at the Section on Military Optometry are: 

First Day 

Factors in Developing a Minimum Optometric Examination 
Routine in the Military 

Second Day 

Malpractice ImpHcationa for the Military Optometrist 
Advantages of AOA Membership for the Military Optometrist 

Third Day 

The Development of Binocular! ty 



Fourth 



Day 



Medical Service Corps Trends 
Report of Contact Liens Research 

Notify Your Commandant of Change 
of Mailing Address 

When you move or change your mailing address, you are required to 
notify the holder of your official naval records of your new address. Report 
address changes as follows: 

Officers: To comnaandant holding your records. If affiliated with a 
pay unit, submit report via your unit CO. 

Enlisted: To your CO, when affiliated with a pay unit. To commandant 
holding your records if you are not a member of a drill pay unit. 



Medical News Letter, Vol. 33, No. 7 



33 



A temporary change of residence of six months or less does not require 
a transfer of records. However, if you have a temporary residence but mail 
cannot be delivered promptly, you should notify the holder of your records of 
your temporary address at the beginning and end of your temporary residence. 

In the event of your death, your next of kin should notify the District 
Couimandant of the fact. 

sAc sfe ik ^ ? t c j rB c 




^^ PREVENTIVE MEDICIIVE SECTION 



Mosquito -Bo me Encephalitis 



During the past Z5 years, severe epidemics of western encephalitis 
(WE) and St. Louis encephalitis (SLE)) have occurred throughout western 
and central United States, but to date no major human outbreaks of eastern 
encephalitis (EE) have been recorded. 

Because of grossly inaccurate and incomplete reporting, the actual 
incidence of "infectious encephalitis" is unknown, but this disease is being 
recognized as an increasingly serious health problem in the United States. 

Information accumulated regarding the natural history of the WE, SLE, 
and EE viruses indicates that wild birds, particularly small species and 
nestlings, are the principal reservoirs of infection and mosquitoes the vectors. 
The basic infection cycle normally is limited to birds and mosquitoes with 
humans and horses as incidental entries. 

Primary vectors of encephalitis include Culex tarsalis for both WE and 
rural SLE in the west and the Culex pipiens complex for urban SLE in central 
United States. Definite knowledge regarding the vectors of EE is lacking, 
but current evidence implicates Culiseta melanura for maintaining the basic 
infection chain in nature (bird-mosquito-bird) and possibly Aedes, Psorophora, 
and Mansonia mosquitoes for transmitting the disease to horses and humans. 

Epidemics appear to be due to a fortuitous set of ecologic conditions, 
including high prevailing temperatures, heavy mosquito populations, and high 
rates of virus infections among nestling and adult birds. 

At present, prevention of encephalitis consists of two principal ap- 
proaches, immunization and mosquito control. Vaccination is recommended 



34 Medical News Letter, Vol. 33, No. 7 



as a prophylaxis for equin.es, but human immunization is not considered 
economically feasible; fxirthermore, suitable vaccines for human use are 
not now available. 

Employment of measures to minimize vector mosquito production in 
areas where encephalitis maybe endemic or epidemic appears to be the 
most practical approach to prevention. Present knowledge indicates that 
control efforts should be focused on C. tarsalis, C. pipiensquinquefasciatus, 
and C, melanura. An alternative possibility which needs further study would 
be the control of avian reservoirs of the viruses. 

Because of the lack of specific therapeutic treatment and lack of suit- 
able human vaccines, coupled with the apparent widespread infection among 
birds and mosquitoes, the encephalitis viruses have a high epidemic poten- 
tial. Hence, it behooves all public health workers to keep well informed on 
the epidemiology of this group of diseases and to maintain continuous vigilance. 
It is hoped that the intensive investigations now imder way will provide a prac- 
tical answer for adequate protection against the mosquito -borne encephalitis 
infections. (Beadle, L. D. , M. A. , Status of Mosquito-Borne Encephalitis in 
the United States: Pub. Health Rep., 74: 84-90, January 1959) 

W- <B* T* V 'ff 'p 

Susceptibility of Garter Snakes to Western 
Equine Encephalomyelitis Virus 

In temperate zones, the importance of a mosquito-bird-mosquito cycle 
for disseminating western equine encephalomyelitis (WEE) virus in summer 
is well established. A major problem, however, in a study of the ecology 
of WEE virus is the overwintering mechanism. One such mechanism sug- 
gested has been a continuing bird-mosquito -bird cycle in warmer climates 
with seasonal invasion of colder climates through migrating birds. Chronic 
latent infection of 1 to 10 months' duration occasionally occurs in wild birds 
experimentally infected with WEE virus which may account for maintenance 
of virus during winter months. However, the WEE virus was not isolated 
from the blood of 764 birds wintering in southern United States, or from 739 
birds entering the same area on their spring migration. The relative paucity 
of evidence that birds served as a winter reservoir of virus or reintroduced 
it into northern areas each year suggested a consideration of hibernating 
animals. With regard to mosqtiitoes themselves, evidence is mounting that 
they are relatively unimportant as a winter reservoir of infection. Hibernating 
vertebrates were considered because on theory of latent infection, such species, 
if susceptible, might serve to maintain virus during winter months and to dis- 
perse it when vectors become active. Field studies showed that Cxolex tarsalis, 
the mosquito vector, overwinters in rock piles atnd that many snakes also 
hibernate in these sites. Laboratory investigations revealed that C. tarsalijs 



Medical New a Letter, Vol. 33, No, 7 35 



feeds on garter snakes in. absence of other hosts, and blood engorged C. 
tarsalis were collected in snake -baited traps. This preliminary report pre- 
sents data showing that garter snakes can be infected readily either by bites 
of infected C. tarsalis or by intraperitoneal inoculation of a recently isolated 
znosquito strain of WEE virus. 

Three snakes were fed upon by 2, 9, and 20 infected mosquitoes, res- 
pectively. Viremia of 4 to 20 days' duration was observed. In one snake, 
virus was detected in a 10~° dilution of whole blood which was the highest 
dilution tested. This quantity of virus in a host is su£Q.cient to infect mos- 
quitoes. 

Four snakes were injected intraperitoneally with a suspension contain- 
ing 10* or 10° L1D50 of virus as determined by titration of the suspension in 
suckling mice. Virus was detected in blood of each snake. The titer of virus 
in one snake was at least 10~'i the highest dilution tested. Virus persisted 
in one snake for 36 days, at which time the snake died. 

Virus isolated from blood of five snakes was identified as WEE virus 
by neutralization test; isolates from two other snakes were presumed to be 
WEE virus because of the characteristic death pattern of suckling mice. 
Antibody titrations in snakes surviving were not carried out. 

This is the first evidence, to the authors' knowledge, that a virus 
which is an important parasite of avian and mammalian hosts csui infect a cold- 
blooded vertebrate and cause viremia of high titer and long duration. The pos- 
sibility that snakes may play a role in overwintering of the virus is being 
investigated, (Thomas, L. A. , et al. , Susceptibility of Garter Snakes 
(Thamnophis Spp. ) to Western Equine Encephalomyelitis Virus: Proc. Soc. 
Exper. Biol. Med,, 99: 698-700, December 1958) 

9{c >{c >|: »!e i^c 1^ 

Probable Biological Control of 
Schistosomiasis Mansoni 

The status of schistosomiasis has been studied intermittently in the Los 
Pena community of the Quebrada San Anton watershed, east of Rio Piedras, 
Puerto Rico. The suburban valley of Los Pena has an area of 10. 3 square 
miles and has 19 tributaries of the main stream Quebrada San Anton as well 
as others adjacent. The terrain consists of rolling hills which gradually 
become an alluvial plain before ending at the Laguna San Jose. The prin- 
cipal stream is normally not more than 10 feet wide and only occasional 
pools are more than 6 feet deep. All tributaries are narrow and shallow. 

The first studies comprised clinical observations on acute and chronic 
cases and determinations of population density and infection rates in the 
snail intermediate host of Schistosoma mansoni, Australorbic glabratus. 
In 1947, the Loe Pena area was used as a test area in which all available 



36 Medical News JLetter, Vol. 33, Ko. 7 



methods of schistoaomiasia control were utilizsed. Treatment with stibo- 
phen and other antimonials was administered^ water supply was improved, 
a latrine was installed at every home, and health education was greatly 
stressed. This study covered a period of 6 years (1947-53). The prev- 
alence of S. mansoni dropped from 44. 6% in. 1947 to 4. 5% 2 years later. 
This case rate decline is am exaniple of the efficacy of stressed health 
education, therapy, and other control measures, but it is also an example 
of the temporary effect of such measures because the infection rate had in- 
creased to 29. 2% by 1953 when the control program ceased. 

In 1950, sodium pentachlorophenate was tested in a section of the main 
stream adjacent to the housing area. The chemical was very effective in kill- 
ing A. glabratus in the area treated and for about 1. 5 miles downstream, but 
snails returned 6 to 8 months later. 

In 1952, the large tropical South American axnpullarid Marisa comua- 
rietis was first seen in the lios Pena section of the stream. By March 1956, 
this snail had advanced upstream for about 1 mile to a small dam only 18 
inches high which temporarily stopped further migration. A gradual decrease 
in Australorbis has been observed in all stream sections where Mariaa has 
become established. However, infected Australorbis continued to be found 
in these reduced colonies during the interim 1952 to 1956, from the main 
stream or tributaries, ranging up to 8% positive. During 1956, infected Aus- 
tralorbis were known to be in only one tributary in the stream system. No 
infected snails have been found since 1956. This finding was based on the 
first snail survey of the entire watershed stream system completed in March 
1956, and repeated bimonthly since then. Australorbis was found to be absent 
from the 1. 5-mile long section of the main stream having the greatest nima- 
bers of Marisa which section includes the Lios Pena community. However, 
the two species were observed living in average numbers (5 to 20 per square 
yard) in some tributaries. 

Watershed populations of Australorbis continued to decline as Marisa 
increased up to October 1957, when only small numbers of the host species 
persisted at three places. The effect of Marisa on Australorbis has been 
studied in the laboratory where it was found that the former snail is a vora- 
cious feeder on vegetation and that it ate Australorbis eggs and reduced num- 
bers of young snails. The number of snails per volume of water was shown 
to be an import ant factor. 

Beginning in March 1956, Marisa has been planted in lots of 200 large 
specimens at all upstream and downstream sections as well as paralotic 
swamps and isolated oxbows. Replantings were made as necessary through 
October 1957. During a period of one and one-half years, it has almost 
eliminated the host species in these areas. 

Two recent successive annual surveys of the same creekside families 
indicate that no new schistosomiasis infections are appearing in the statis- 
tically sensitive preschool age group. The commvuiity prevalence in all ag«« 



Medical News Letter, Yol. 33, No. 7 37 



and both sexes has levelled off at a rate of about 6 or 7%. This first instance 
of probable biological control of schiatosomiasis transmission, should be re- 
peated in other endemic environments which are capable of supporting the 
remarkable snail Marisa. This field test is a step toward the solution of 
certain control problems in Puerto Hicaui schistosomiasis on a permanent and 
economically feasible basis. (Oliver -Gonzalez, J. , Ferguson, F. F. , Prob- 
able Biological Control of Schistosomiasis Mansoni in a Puerto Rican Water- 
shed: Am. J. Trop. M. Hyg. , 8^: 56-59, January 1959) 

sk sk 3^ sfic jk ^ 

Artificial Respiration Without Adjunct Equipment 

(The following memorandum from the National Research Council, National 
Academy of Sciences, dated 16 February 1959» is reproduced for the infor- 
mation of the Service. ) 

••There is enclosed for your information a copy of a 'Statement on 
Emergency Artificial Respiration Without Adjunct Eqxiipment' which has 
been approved by the Division of Medical Sciences of the Academy-Research 
Council. 

This statement simply endorses the use of the raouth-tq -mouth method 
of producing artificial respiration as the most practical tnethod for wide- 
spread use. 

It should be emphasized that this statement does not consider the 
relative values of various types of adjunct equipment or details of techniques 
and teaching methods. It is concerned primarily with a situation in which 
there is an urgent need to provide artificial respiration by the first person 
on the scene. The points presented in the statement would need considerable 
expansion to cover the many details of techniques to be used and the problems 
associated with teaching. " 

Statement on Emergency Artificial Respiration Without Adjunct Equipment 

"The National Academy of Sciences -National Research Council Ad Hoc 
Committee on Artificial Respiration in its meeting of 3 November 1958 
reviewed the data on artificial respiration obtained through research pro- 
jects supported by the Department of the Army, the American National 
Red Cross, and others. 

It was unanimously agreed by members of the Ad Hoc group that the 
mouth -to -mouth (or mouth-to-nose) technique of artificial respiration is 
the most practical method for emergency ventilation of an apneic individual, 
of any age, in the absence of equipment or of help from a second person, 
regardless of the cause of apnea. This method has the advantage of 



38 



Medical News Letter, Vol. 33, No. 7 



providing pressure to innate the victim's lungs immediately amd allowing 
the rescuer to gain some information on the pressure, volume and dura- 
tion of each blowing effort. For adults, a rate of about twelve breaths 
per minute of twice the normal volume was recommended; for children 
relatively shallow breaths appropriate for their size at a rate of about 
twenty per minute. For infants, only shallow puffs should be used. 

The most important single factor contributing to the rescuer's success 
by any method is the immediate introduction of air into the victim's liuigs. 
This can be accomplished only through an open airway. Mouth -to -mouth 
artificial respiration should be started at the earliest possible moment. 
The victim should be placed in a supine position with his head tilted back- 
ward and the lower jaw displaced forward. These two maneuvers relieve 
obstruction of the air'way by the tongue by moving the tongue away from 
the back of the throat. 

If obstructing foreign material is obviously present, such as food par- 
ticles, secretions, false teeth, blood or blood clots, or chewing gum, it 
must be removed immediately with the fingers or by any other means pos- 
sible. The first blowing effort will determine whether or not obstruction 
exists and, in the absence of obstruction, will provide the urgently needed 
oxygen. 

If aspiration of a foreign body is suspected in an adult after failure of 
mouth-to-mouth ventilation to move air into the lungs, the victim should 
be placed on his side and a sharp blow administered between the shoulders 
to jar the obstructing material free. Again, the rescuer's fingers should 
sweep through the victim's mouth to remove such material. 

An asphyxiated small child suspected of having a foreign body in the 
airway should be suspended momentarily by the ankles, or inverted over 
one arm and given two or three sharp pats between the shoulder blades 
in tile hope of dislodging obstructing material. 

Three important points should be stressed in the teaching of mouth- 
to-mouth methods: (1) Tilt the head backward and displace the lower jaw 
forward to clear the airway; (2) Prevent air leakage; (3) Blow vigorously 
into adults, but gently into children. 

To avoid over -distension, the lungs should not be inflated beyond the 
point where the rescuer sees the victitti's chest or abdomen expand. 

Those rescuers who, for any reason, cannot or will not use the mouth- 
to-mouth technique should use a manual method. The Committee believes 
that there are not sufficient data available to recommend any single manual 
method as the best for all circumstances. Of the several manual methods 
available, some are more effective than others under different circum- 
stances, and they vary in the amount of fatiguing strain placed upon the 
operator. The rescuer should not be limited to the use of a single man- 
ual method for all cases because the nature of the injuries in any given 
case may prevent the use of one method while favoring another. 



Medical News L-etter, Vol. 33, No. 7 39 



The supine chest pressure-arm lift method (Silvester), with an impro- 
vised support under the shoulders, provides a slightly increased tidal 
volume when compared to prone push-pull methods, hut in the supine 
position there is daoiger of aspiration of vomitus, blood, or blood clots. 
This hazard can be reduced by keeping the head extended and turned to 
one side. If possible, the head should be a little lower than the trunk. 

The prone pressure, arm lift, hands under the face method (Holger- 
Nielsen) also presents a hazard of eiirway obstruction unless great care 
is taken to keep the head extended. The claimed advantage of prone 
methods over the supine methods of providing more efficient gravity 
drainage is minimal, and the prone method has the disadvantage, well 
recognized by anesthetists, of producing some restriction of breathing. 

When manual methods are being used and a second rescuer becomes 
available, his efforts should be directed towards maintaining an open 
airway by holding the head and neck properly, maintaining forward dis- 
placement of the jaw, and keeping the pharynx free of vomit or mucus. 

Eegardless of the method used, the preservation of an open airway is 
essential. This can best be done by assuring continued extension of the 
head and neck and forward displacement of the lower jaw. Some uncon- 
scious victims will be saved simply by the establishment of an open air- 
way permitting spontaneous breathing. " 

NOTE: The following references are recommended for details of techniques 
to be used and the methods of teaching artlHcial respiration: 

Armed Forces Medical Journal, June 1957 
Medical Technicians Bulletin, May-June 1957 
Syllabus of Lesson Plans for First-Aid Instrxictors, 

NavMed P-5056 
First Aid, American National Red Cross, Fourth Edition 

Films are available for scheduled loan from the Research Film Section, 
Walter Reed Army Institute of Research, Washington 12, D. C. Attention: 
M. Sgt. H. E. Dixon. (Two additional films intended for technical personnel 
will be available in the near future, ) 

Respiration Resuscitation Techniques - 40 minutes. For use by tech- 
nical personnel. Compares all methods of resuscitation, including the 
mouth-to-mouth and mouth-to-airway techniques. 

Mouth -to -Mouth Rescue Breathing - 10 minutes. For use by aid per- 
sonnel, first-aid groups, and schools. Technique only. 

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40 



Medical News Letter, Vol. 33, No. 7 



Navy's Motor Vehicle Traffic Safety Course 

CMSW Ralph T. Goemer, Jr. , USN, Head, Safety Section, Health 
Practices Branch, Preventive Medicine Division, Bureau of Medicine and 
Surgery, attended the first Navy course in Motor Vehicle and Traffic Safety 
conducted for the Navy by the Traffic; Institute, Northwestern University, 
Evanston, 111. , February 2 - 20, 1959. The following subjects were presented: 



Accident Causes, Investigation, 
Reconstmiction, and Analysis 

Use of Accident Record Data 

Motor Vehicle Administration 

Traiffic Engineering 

Driver Improvement through 
Education 



Traffic Ltaw Enforcement - Police 

and Courts 
Chemicskl Tests for Intoxication 
Principles of Coordination of 

Safety Program 
General Semantics 
Military Traffic Safety Program 



The Traffic Institute has valuable data and techniques to offer, and the 
course in Motor Vehicle and Traffic Safety is highly recommended for officer 
personnel assigned to Security Officer billets and for civilian transportation 
supervisors and safety workers. Army and Air Force personnel attended the 
Institute and both Services feel that this course has contributed a great deal 
to their decreased accident rate. 

The second Navy Course is scheduled for November 30 - December 18, 
1959. (Safety Section, Health Practices Branch, PrevMedDiv, BuMed) 

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